Different traits for cold tolerance of extremely thermophilic Calditerricola strains isolated from mesothermal municipal sewage sludge and its hyperthermal compost.

Extreme thermophiles Calditerricola satsumensis DD2 and D3 were isolated from mesothermal municipal sludge, a material used for hyperthermal composting. To understand the ecologically anomalous findings, their behavior at various temperatures, membrane fatty acid composition, and draft genome sequences were compared with those of C. satsumensis YMO81T and Calditerricola yamamurae YMO722T, already isolated from hyperthermal compost. All four strains grew between 56 and 83 °C. However, strains DD2 and D3 were stable for ≥48 h at a wide range of temperatures (20-75 °C), while strains YMO81T and YMO722T were highly labile at lower temperatures. The former strains maintained their colony-forming ability for >180 days at 20 °C, while the latter strains lost it within 1 d. All four strains showed similar composition of membrane fatty acid, which were not affected by 20 °C treatment. Comparative draft genome analyses showed that 13 candidate genes were present only in strains DD2 and D3, and the specific expression of six gene homologs was confirmed. A DNA chaperone, site-specific recombinase XerD homolog, had tetra adenine sequence at its upper gene region, and was up-regulated by 20 °C treatment in DD2 and D3, suggesting a possible role in the cold tolerance of sludge-derived strains. In addition, the lack of another possible DNA chaperone, a homolog of the ATP-dependent DNA helicase, in the compost-derived strains may accelerate their sensitivity to cold shock. In conclusion, we speculate that the specific phenotypic and genotypic characteristics of sludge-derived strains are responsible for their unusual ecological distribution at ambient temperatures.

Clinical Experience of Using an 8 French Newton Shaped Catheter (Neuro-EBU) During Endovascular Treatment: A Case Series of 21 Patients.

The first step in endovascular treatment is the stable placement of a guide catheter (GC) into the target parent vessel. However, sufficient GC stabilization is sometimes difficult to obtain when the approach route has severe tortuosity. Here, we report our experience with and the usefulness of the 8 French (Fr) Newton-shaped Neuro-EBU vascular catheter (SILUX Co., Ltd., Kawaguchi City, Saitama Prefecture, Japan), which is rigid over its entire length except near the tip, in a case series of 21 patients. Of the 21 cases, 19 cases were successfully treated using the Neuro-EBU. The 8 Fr Newton-shaped Neuro-EBU might be useful both as a special GC and as a wire exchange catheter when placement of the conventional GC is difficult due to severe tortuosity of the access route. Although rarely used, the Neuro-EBU catheter can serve as a practical alternative when the access route is challenging. To the best of our knowledge, there are no detailed reports on the technical use of the Newton-shaped vascular catheter in the field of neurointervention. We present the usefulness of the specially shaped 8 Fr guide catheter.

Indications for computed tomography use and frequency of traumatic abnormalities based on real-world data of 2405 pediatric patients with minor head trauma.

BACKGROUND: In pediatric patients with minor head trauma, computed tomography (CT) is often performed beyond the scope of recommendations that are based on existing algorithms. Herein, we evaluated pediatric patients with minor head trauma who underwent CT examinations, quantified its frequency, and determined how often traumatic findings were observed in the intracranial region or skull. METHODS: We retrospectively reviewed the medical records and neuroimages of pediatric patients (0-5 years) who presented at our hospital with minor head trauma within 24 h after injury. RESULTS: Of 2405 eligible patients, 1592 (66.2%) underwent CT examinations and 45 (1.9%) had traumatic intracranial hemorrhage or skull fracture on CT. No patient underwent surgery or intensive treatment. Multivariate analyses revealed that an age of 1-5 years (vs. <1 year; P < 0.001), Glasgow Coma Scale (GCS) score of 14 (vs. a score of 15; P = 0.008), sustaining a high-altitude fall (P < 0.001), using an ambulance (P < 0.001), and vomiting (P < 0.001) were significantly associated with the performance of CT examination. In addition, traumatic abnormalities on CT were significantly associated with the combination of an age of under 1 year (P = 0.042), GCS score of 14 (P < 0.001), and sustaining a high-altitude fall (P = 0.004). CONCLUSION: Although slightly broader indications for CT use, compared to the previous algorithms, could detect and evaluate minor traumatic changes in pediatric patients with minor head trauma, over-indications for CT examinations to detect only approximately 2% of abnormalities should be avoided and the indications should be determined based on the patient's age, condition, and cause of injury.

Effects of gait training with a voluntary-driven wearable cyborg, Hybrid Assistive Limb (HAL), on quality of life in patients with neuromuscular disease, able to walk independently with aids.

Robot-assisted gait training using a voluntary-driven wearable cyborg, Hybrid Assistive Limb (HAL), has been shown to improve the mobility of patients with neurological disorders; however, its effect on the quality of life (QOL) of patients is not clear. The aim of this study was to assess the effects of HAL-assisted gait training on QOL and mobility in patients with neuromuscular diseases (NMDs). Ten patients with NMDs (seven men and three women, mean age: 57 ± 11 years), with impairment in mobility but could walk alone with aids underwent two courses of gait training with HAL over 6 months, and the single course consisted of nine sessions of training for 4 weeks. We compared the findings of the 2 min walk test, 10 m walk test, the Short Form-36 (SF-36) questionnaire, and the Hospital Anxiety and Depression Scale at baseline, after the 1st training, before the 2nd training, and after the 2nd training using the Friedman test. A significant improvement was observed in the 2 min walking distance from baseline (93 ± 50 m) to after the 2nd training (115 ± 48 m, P = 0.034), as well as in the domains of vitality (P = 0.019) and mental component summary score (P = 0.019) of SF-36. The improvement in 10 m walking speed was significantly correlated with that in the physical functioning (R = 0.831, P = 0.003) and role physical (R = 0.697, P = 0.025) domains in the SF-36. Our findings suggest that HAL-assisted gait training is effective in improving QOL associated with mental health as well as gait ability in selected patients with NMDs.

Coiling for a saccular aneurysm on the caudal channel in double origin of the posterior inferior cerebellar artery.

BACKGROUND: Double origin of the posterior inferior cerebellar artery (DOPICA) is a rare cranial imaging finding with an incidence of 0.36-6% reported in various retrospective studies. Aneurysms on a DOPICA are even rarer. CASE DESCRIPTION: A 34-year-old women hospitalised for subarachnoid haemorrhage showed a ruptured aneurysm arising from the caudal channel of the DOPICA. Endovascular treatment was selected, and the aneurysm was successfully and completely embolised using two coils. CONCLUSIONS: To date, a total of three previous saccular aneurysms of the DOPICA itself have been reported, all of which were treated using endovascular methods. Our case is the first report of a ruptured saccular aneurysm arising from the non-branching segment of the caudal channel of the DOPICA.

Multidisciplinary Treatments of True Posterior Inferior Cerebellar Artery Aneurysms: Single-Center Retrospective Study and Treatment Algorithm.

BACKGROUND: True posterior inferior cerebellar artery (PICA) aneurysms outside the vertebral artery-PICA region are rare, with approximately 30 cases reported in just a few papers; no treatment paradigm has been advocated. The objective of this study was to present detailed clinical features and outcomes for several treatments for true PICA aneurysms and suggest an algorithm for treatment strategies. METHODS: We retrospectively analyzed outcomes of patients treated for PICA aneurysms with microsurgical and endovascular treatments. We also investigated the influence of several factors on the modified Rankin Scale score. RESULTS: Cases with PICA aneurysms (n = 36) outside the vertebral artery-PICA region were identified angiographically. Aneurysm locations included anterior medullary (n = 7), lateral medullary (n = 10), tonsillomedullary (n = 4), telovelotonsillar (n = 12), and cortical (n = 3) segments of the PICA. Aneurysm morphology was as follows: dissecting: 22; fusiform: 6; and saccular: 8. On multivariate analysis, age (P = 0.028) and lack of vermian infarction (P =0.037) were associated with a significantly better prognosis. Prognosis was not significantly different for the 5 aneurysm locations and among the 4 treatment groups: clipping/coiling, trapping/parent artery occlusion, trapping/parent artery occlusion + bypass, and observation including external ventricular drainage. CONCLUSIONS: This study suggests that factors associated with significantly better prognosis include age, clip/coil treatments, and no vermian infarction complication. A treatment algorithm for true PICA aneurysms was supported according to pretreatment H and K grade, PICA segments, aneurysm morphology, and 3 types of ischemia linked to the brainstem, cerebellar hemisphere, or vermis.

Coiling for an unruptured saccular aneurysm at the non-branching segment of the distal anterior cerebral artery: Case report and literature review.

BACKGROUND: Saccular aneurysms in the non-branching segment of the distal anterior cerebral artery (DACA) are extremely rare. Here, we describe the first case of coil embolization using a simple, non-adjunctive technique for an aneurysm at this rare location. CASE DESCRIPTION: A 74-year-old man with an asymptomatic, unruptured aneurysm of the right DACA was followed up annually for 3 years by medical checkup. Endovascular treatment was proposed because of a slight angiographic change in the shape of the aneurysm in the past year. The aneurysm at the non-branching site of the right calloso-marginal artery was 2 mm distal to the origin, and measured 3 mm in height and 3.3 mm in width, with a neck measuring 1.7 mm wide; the calloso-marginal artery diameter was 1.6 mm. The aneurysm was successfully embolized with a simple technique using a Pre-Shaped S Microcatheter and two coils. CONCLUSIONS: The simple, non-adjunctive technique for coil embolization of saccular side-wall type aneurysm in the non-branching segment of the DACA could be performed using the appropriate catheter and a softer coil.

Mechanical Thrombectomy for Basilar Artery Occlusion Compared with Anterior Circulation Stroke.

OBJECTIVE: To investigate the clinical effectiveness of mechanical thrombectomy (MT) for basilar artery occlusion (BAO) and to ascertain whether outcomes for patients with BAO were comparable to those with anterior circulation large vessel occlusion (ACS). METHODS: A total of 345 patients who underwent MT between 2011 and 2018 were grouped by occlusion site (295 patients with ACS and 50 patients with BAO). Patients' baseline characteristics, procedural times, complications, symptomatic intracranial hemorrhage, modified Rankin Scale score, and mortality at 90 days were analyzed. RESULTS: Male preponderance (66.0% vs. 48.8%; P = 0.0316), younger age (72.5 years [interquartile range (IQR), 64.75-78.5 years] vs. 77 years [IQR 69-84 years]; P = 0.0297), higher National Institutes of Health Stroke Scale score (24.5 [IQR, 13-32] vs. 18 [IQR 13-22]; P = 0.0015) and higher reperfusion rate (100% vs. 84.7%; P = 0.0010) were observed in patients with BAO. We found no significant difference in favorable outcomes (modified Rankin Scale score ≤2) between patients with BAO and patients with ACS (64.3% vs. 49.3%; P = 0.0914). In multivariate analysis, Alberta Stroke Program Early Computed Tomography Score (odds ratio [OR], 1.282; 95% confidence interval [CI], 1.090-1.524; P = 0.0024), time from onset to reperfusion (OTR) (OR, 0.9950; 95% CI, 0.992-0.998; P = 0.0008), successful reperfusion (OR, 6.953; 95% CI, 1.576-48.729; P = 0.0092), and hemorrhagic complication (OR, 0.352; 95% CI, 0.151-0.797; P = 0.0122) were associated with a favorable outcome at 90 days in patients with ACS. In patients with BAO, only OTR (OR, 0.9879; 95% CI, 0.974-0.999; P = 0.0314) was associated with a favorable outcome at 90 days. CONCLUSIONS: MT may be considered the standard care for patients with BAO. OTR was the only common significant predictor for favorable outcomes in both patient cohorts.

Mechanical Thrombectomy of Primary Distal Anterior Cerebral Artery Occlusion: A Case Report.

OBJECTIVE: Primary anterior cerebral artery (ACA) occlusion is a rare condition and sometimes leads to significant neurological deficits. We herein report on the efficacy of mechanical thrombectomy (MT) in treating the distal ACA occlusion in a clinical setting. CASE PRESENTATION: A 76-year-old woman presented with a sudden onset of right hemiparesis. Computed tomographic angiography and perfusion imaging and subsequent analysis with RAPID software revealed acute left ACA occlusion with salvageable penumbra. The patient obtained a score of 11 on the National Institutes of Health Stroke Scale. MT was performed for occlusion of the left ACA (A4), and successful reperfusion (Thrombolysis in Cerebral Infarction score of 3) was achieved on the first attempt using a stent retriever. The patient's recovery progressed well, and she was discharged 13 days after admission with a modified Rankin Scale score of 1. CONCLUSION: This case report demonstrates the clinical efficacy, safety, and favorable clinical outcome of treating a primary distal ACA occlusion with MT.

A Direct Aspiration First Pass Technique in Japanese Real-World Clinical Setting.

BACKGROUND: It is debatable whether mechanical thrombectomy has benefits in a real-world setting outside the more rigid and selective clinical trial environment. OBJECTIVE: To evaluate clinical outcomes, efficacy, and safety of mechanical thrombectomy in single-center retrospective cohort case series. METHODS: We reviewed prospectively collected data from our large-vessel occlusion stroke database to identify patients undergoing mechanical thrombectomy using Penumbra catheters (Penumbra, Almeida, California) as first-line devices. The primary outcomes were the modified Rankin Scale score at 90 d and recanalization rate. The secondary outcomes included the rates of hemorrhagic complications and mortality. RESULTS: The entire study population included 298 patients. Thrombolysis in Cerebral Infarction Scale ≥2b was achieved in 86.6% of patients. Fifty-five patients (18.5%) were outside the 6 hr time window and 82 patients (27.5%) were over 80-yr old. The posterior circulation thrombectomy rate was 12.4%. At 90 d from onset, 49.3% of patients had favorable outcomes. The parenchymal hemorrhage type 2 (PH2) and subarachnoid hemorrhage rates were 2.3% and 11.7%, respectively. In multivariate analyses, cerebral blood flow/cerebral blood volume mismatch (odds ratio [OR] = 9.418; 95% confidence interval [CI], 3.680-27.726; P < .0001), onset to recanalization time (OR = 0.995; 95% CI, 0.991-0.998; P = .0003), and hemorrhagic complications including PH2 and subarachnoid hemorrhage (OR = 0.186; 95% CI, 0.070-0.455; P = .0002) were associated with favorable outcomes. CONCLUSION: A direct aspiration first pass technique with an adjunctive device demonstrated high recanalization rates in old Japanese patients. Our patient cohort may reflect the application of endovascular techniques in acute ischemic stroke treatment in a real-world setting.

Novel microguidewire-assist (MGA) manoeuver for coil embolisation of an unruptured middle cerebral artery aneurysm.

We describe here a novel yet very simple technique, called microguidewire-assist (MGA) manoeuvre, for coil embolisation of unruptured intracranial aneurysms. A 79-year-old woman with a small, broad-necked middle cerebral artery (MCA) bifurcation aneurysm that incorporated the orifice of the acute-angled M2 superior trunk underwent coil embolisation. Since the balloon assist technique was not feasible, we inserted and retained only the microguidewire through M1 to the M2 superior trunk; subsequently, with appropriate use of the microguidewire, coil embolisation was completed. The MGA manoeuvre resulted in slight vessel straightening and subsequent changes in the angulation of the aneurysmal neck, with which stable placement of the platinum coil was successfully accomplished. For coil embolisation of small, broad-necked MCA aneurysms that partially straddle the M2 trunk, this manoeuvre might provide an effective therapeutic alternative if other techniques are not feasible.

Basilar Artery Occlusion with "Seizures" as a Presenting Symptom: Three Cases Treated Using Mechanical Thrombectomy.

BACKGROUND: Basilar artery occlusion (BAO) is a rare, potentially fatal cause of ischemic stroke. It is often challenging to diagnose, especially when the presenting symptom is "seizures". We present 3 cases of patients with BAO presenting with seizures. CASE DESCRIPTION: The first patient was a 53-year-old man with clonic convulsions. On angiography, BAO was detected and mechanical thrombectomy (MT) was performed. The modified Rankin Scale score at 3 months after treatment was 1. The second patient was a 64-year-old man with generalized convulsions. He was diagnosed with BAO and vertebral artery dissection and was treated with MT, percutaneous transluminal angioplasty, and stenting. The modified Rankin Scale score at 3 months after treatment was 3. The third patient was a 77-year-old man with tonic convulsions. He was diagnosed with BAO and treated with MT. However, he did not survive. CONCLUSIONS: BAO is devastating; however, it is a treatable disease. Our report suggests that BAO should be suspected in patients presenting with initial convulsive seizures.

Recurrence in 787 Patients with Chronic Subdural Hematoma: Retrospective Cohort Investigation of Associated Factors Including Direct Oral Anticoagulant Use.

OBJECTIVE: Chronic subdural hematoma (CSDH) is a highly recurrent disorder. Although some predictors including the use of antithrombotic agents such as aspirin and warfarin have been proposed, the pathogenic mechanism involved remains unclear. Moreover, the link between direct oral anticoagulant (DOAC) agent use and CSDH recurrence has not been reported. The aim of this study was to investigate factors including DOAC use that could potentially be associated with CSDH recurrence. METHODS: The authors analyzed 787 patients with CSDH who underwent surgery for CSDH with 1 burr-hole irrigation at Baba Memorial Hospital from January 2012 to November 2017. The patients were divided into recurrence and nonrecurrence groups and anticoagulant, antiplatelet, and control groups. Recurrence was defined as ipsilateral hemorrhage within 90 days from the original operation. Variables with P < 0.1 in the univariate analysis were included in a multivariate logistic regression model. RESULTS: CSDH recurrence was observed in 12.2% of patients, and significantly more men (80.2%) than women experienced recurrence. Age, sex, and warfarin use were entered in the multivariate analysis, and it was revealed that age and male sex were independently associated with CSDH recurrence. Antithrombotic agent use including use of DOACs was not associated with increased CSDH recurrence. CONCLUSIONS: The present study found that age and male sex were independently associated with CSDH recurrence, while the use of antithrombotic agents was not.

A case of delayed distal coil migration after coil embolization of an unruptured distal azygos anterior cerebral artery aneurysm: A case report and literature review.

Intraprocedural coil migration during endovascular treatment for an aneurysm that might carry serious ischemic complications is well known. On the other hand, delayed coil migration after endovascular treatment for an aneurysm is very rare. A 77-year-old woman was incidentally diagnosed with unruptured aneurysm associated with distal azygos anterior cerebral artery (ACA). The aneurysm was located at the distal bifurcation of the azygos ACA and was wide necked (approximately 7 mm in diameter). Endovascular coil embolization was selected and the aneurysm was occluded successfully, but 29 days after endovascular therapy, follow-up computed tomography (CT) and magnetic resonance (MR) angiography revealed distal coil migration in the peripheral portion of the ACA. In addition, CT on day 57 after therapy revealed the migrated coil had moved more distally. Fortunately, in the course of these events, the patient remained asymptomatic. To the best of our knowledge, this represents the first case of delayed distal coil migration associated with relatively rare azygos ACA aneurysm, and also the first report confirming more distal coil movement over time. In the future, a large number of patients could develop this complication as more aneurysms are aggressively treated with endovascular treatment. Knowledge regarding the possibility of delayed coil migration is thus important.

[Coil Embolization for Very Small Intracranial Aneurysms with Diameter Less than 3mm:A Case Series of 14 Patients and Literature Review].

INTRODUCTION: Many studies describe aneurysms measuring ≤3mm as "very small" or "tiny, " with a risk of intraoperative rupture higher than that of most cerebral aneurysms. We evaluated the results of endovascular coil embolization for very small aneurysms with diameter ≤3mm. MATERIAL AND METHODS: The same interventional neurosurgeon performed coil embolization for 14 tiny aneurysms in 14 patients(8male and 6 females)at our institution between May 2015 and June 2017. Patient age range was 42-88 years(average 65.6 years). Five aneurysms had ruptured and 9 were unruptured. Of the 9 unruptured aneurysms, 3 were associated with a previous ruptured aneurysm. We assessed the procedural complications, type of microcatheter and coils used, total number and length of coils, and angiographic results immediately after the procedure. RESULTS: In 14 aneurysm cases, 8 used only 1 pre-shaped microcatheter, 4 used 2, and 2 used 3;cases using multiple microcatheters added final shaping. Only one case used a helical first coil and the remaining 13 cases used a 3-dimensional coil. The number of coils used was 1 in 3 cases, 2 in 7 cases, 3 in 2 cases, and 4 in 2 cases. The total length of coils inserted was <5 cm in 5 cases, 5-10 cm in 5 cases, and >10 cm in 4 cases. The total length of coils used was <10cm in 70% of cases. Immediately after coil embolization, complete occlusion and a neck remnant were achieved in 11 and 3 cases, respectively. Ballooning was induced by intentionally introducing a balloon-assist technique during surgery in 7 cases, and the balloon was actually inflated in 4 cases. Complications were seen in 2 ruptured cases;1 had an intraoperative rupture, the other had parent artery occlusion, and both patients recovered. CONCLUSION: Coil embolization for tiny aneurysms can be performed comparatively safely by understanding the pitfalls and by using appropriate procedures and tools. Placing the catheter tip at the aneurysm neck is the first step and endovascular treatment is usually performed with ≤3 coils measuring ≤10 cm in total length. Complete embolization should be attempted, but even incomplete embolization is acceptable. More delicate coil embolization is required.

Optimal thresholds for ischemic penumbra predicted by computed tomography perfusion in patients with acute ischemic stroke treated with mechanical thrombectomy.

BACKGROUND AND PURPOSE: Optimal thresholds for ischemic penumbra detected by CT perfusion (CTP) in patients with acute ischemic stroke (AIS) have not been elucidated. In this study we investigated optimal thresholds for salvageable ischemic penumbra and the risk of hemorrhagic transformation (HT). METHODS: A total of 156 consecutive patients with AIS treated with mechanical thrombectomy (MT) at our hospital were enrolled. Absolute (a) and relative (r) CTP parameters including cerebral blood flow (aCBF and rCBF), cerebral blood volume (aCBV and rCBV), and mean transit time (aMTT and rMTT) were evaluated for their value in detecting ischemic penumbra in each of seven arbitrary regions of interest defined by the major supplying blood vessel. Optimal thresholds were calculated by performing receiver operating characteristic curve analysis in 47 patients who achieved Thrombolysis In Cerebral Infarction (TICI) grade 3 recanalization. The risk of HT after MT was evaluated in 101 patients who achieved TICI grade 2b-3 recanalization. RESULTS: Absolute CTP parameters for distinguishing ischemic penumbra from ischemic core were as follows: aCBF, 27.8 mL/100 g/min (area under the curve 0.82); aCBV, 2.1 mL/100 g (0.75); and aMTT, 7.30 s (0.70). Relative CTP parameters were as follows: rCBF, 0.62 (0.81); rCBV, 0.83 (0.87); and rMTT, 1.61 (0.73). CBF was significantly lower in areas of HT than in areas of infarction (aCBF, p<0.01; rCBF, p<0.001). CONCLUSIONS: CTP may be able to predict treatable ischemic penumbra and the risk of HT after MT in patients with AIS.

[Five Cases of Neuroendovascular Treatment Using the Goose Neck Snare for Inducing and Holding the Guiding Catheter].

The stabilization of a guiding catheter is a very important factor for successful endovascular treatment. However, it is sometimes difficult to obtain sufficient stabilization because of the tortuosity of the approach route. A Goose Neck Snare is useful for the retrieval of intravascular foreign bodies and can be used to hold the guiding catheter. We describe five cases of endovascular treatment performed while using the Goose Neck Snare via the brachial artery to hold the guiding catheter. We discuss the utility of this strategy.

A case with coil embolization for ruptured aneurysm associated with fenestration of the posterior inferior cerebellar artery.

An 87-year-old man hospitalized for subarachnoid hemorrhage showed a ruptured aneurysm arising from fenestration of the posterior inferior cerebellar artery. Endovascular treatment was selected and the aneurysm and superior limb were embolized completely using three coils. Fenestration of the posterior cerebellar artery is exceedingly rare. In addition, we present a first case of aneurysm as fenestration of the posterior inferior cerebellar artery that was definitively identified as a cause of bleeding.

Mechanical Thrombectomy for Acute Basilar Artery Occlusion in Early Therapeutic Time Window.

BACKGROUND: The natural history of basilar artery occlusion (BAO) is devastating, with morbidity rates increasing up to 80%. However, the efficacy of recanalization therapy for BAO has not been established as yet. OBJECTIVE: We analyzed consecutive cases of BAO treated with mechanical thrombectomy (MT) to evaluate its safety and efficacy and to determine factors associated with the prognosis. METHODS: Between October 2011 and September 2016, MT was performed in 34 patients with BAO. MT was performed using the Penumbra system and stent retriever. CT perfusion was used for evaluating patients. Cerebral blood flow (CBF) maps and cerebral blood volume (CBV) maps were evaluated. CBF/CBV mismatch was defined as ≥50% penumbra. Clinical outcomes were correlated with demographic, clinical, and radiographic findings. RESULTS: The median baseline National Institutes of Health Stroke Scale score was 29 (14-33). The recanalization rate (≥thrombolysis in cerebral infarction grades 2b) was 100%. The median onset to recanalization time (OTR) was 197 (160-256) min. Favorable outcomes (modified Rankin Scale ≤2) at 90 days occurred in 56% (n = 19 of 34). The mortality rate at 90 days was 12% (n = 4 of 34). In univariate analysis, intravenous (IV) recombinant tissue-type plasminogen activator (rt-PA) use, and OTR were significantly associated with favorable outcomes. In a multivariate logistic regression model, IV rt-PA use and lower National Institute of Health Stroke Scale score were significantly related to favorable outcomes. Conclusion and Relevance: Multimodal endovascular therapy using the Penumbra system and stent retriever demonstrated a high recanalization rate and favorable outcomes for BAO. Both devices were feasible and effective in the treatment of BAO. An approach combining MT with IV thrombolysis provided a better recanalization rate and more favorable clinical outcomes.

[A Case of Middle Cerebral Artery Stenosis Presented with Limb-Shaking TIA].

Involuntary movement is a rare clinical manifestation of transient ischemic attack (TIA). However, limb-shaking TIA is well described presentation of carotid occlusive disease. We present the case of a patient who developed limb-shaking TIA associated with high-grade stenosis of middle cerebral artery (M1), which was treated with percutaneous transluminal angioplasty (PTA). The procedure was performed successfully without complication and the symptom disappeared immediately after the procedure. The patient remained free of symptoms at the 38-month follow-up. There was no tendency of restenosis of M1. In this case, PTA was technically feasible and beneficial for limb-shaking TIA with M1 stenosis. Limb-shaking TIA can be a symptom of high-grade stenosis of M1.